Wounds of War: Syria's Hospitals, Doctors, and Volunteers Under Attack

Syria's government is trying to quash a rebellion by bombing hospitals. Still, brave doctors -- many of them American volunteers -- are risking everything to save lives. In besieged East Ghouta, Syria, nearly 400,000 civilians are facing severe shortages of basic goods and lifesaving medical care. In its latest brief, "Under Siege: The Plight of East Ghouta," SAMS highlights the devastating impact of the four-year long blockade on the health sector and underscores the pressing need to break the siege.

(November 26, 2017) -- Syria's dictator is trying to quash the remnants of rebellion by bombing hospitals. Still, brave doctors in the country -- many of them American volunteers -- are risking everything to save lives. Scott Pelley reports.

The Syrian American Medical Society (SAMS) is a nonpolitical, nonprofit medical relief organization that is working on the front lines of crisis relief in Syria and neighboring countries to alleviate suffering and save lives. SAMS proudly provides medical care and treatment to every patient in need.

"Many patients are simply awaiting their death at home."
-- A SAMS doctor in East Ghouta

Nearly 400,000 civilians living in besieged East Ghouta are facing severe shortages of basic goods and lifesaving medical care. In its latest brief, Under Siege: The Plight of East Ghouta, SAMS highlights the devastating impact of the four-year long blockade on the health sector and underscores the pressing need to break the siege.

Only 107 doctors, including one oncologist and one neurosurgeon, remain to treat the nearly 400,000 residents of East Ghouta. These physicians, in many circumstances, are not able to provide much more than a diagnosis due to the severe shortages of medications and surgical supplies. Contagious diseases including salmonella, measles and tuberculosis, have spread. In July 2017, SAMS medical staff reported nearly 600 cases of typhoid in the besieged area.

The brief also details the ongoing difficulties in securing approval for medical evacuations of critical cases. In August 2017, four children died in East Ghouta waiting for permission to be evacuated.

On September 23, 2017, five-year-old Osama lost his life due to acute herpetic encephalitis. Acyclovir, the antiviral medication needed to save his life, was available just kilometers away in Damascus. A list of 330 patients has been shared with health actors in Damascus for evacuation, to no avail.

Under Siege: The Plight of East Ghouta highlights the effects of the "surrender or starve" tactic that is utilized in at least 34 besieged communities across Syria. Immediate steps must be taken to end the siege in East Ghouta and all other besieged areas in Syria.

UNDER SIEGE: The Plight of East Ghouta

On September 11, a medical facility in East Ghouta was targeted by artillery shelling, killing one patient and injuring four medical personnel and four patients. The attack completely destroyed two medical vehicles and forced the medical facility to temporarily close. Two days later, a private hospital was targeted, injuring one member of the medical staff and two patients.

Last month marked the fourth anniversary of the August 2013 chemical attack that took the lives of more than 1,200 people in East Ghouta, one of the largest suburbs in Rural Damascus. Once a lively agricultural area inhabited by more than 1.2 million people, its population is currently estimated at around 400,000, one-third of whom are internally displaced persons (IDPs). (1)

In October 2013, the Syrian government imposed a stifling siege on East Ghouta after months of cutting access to basic necessities including electricity, potable water, and telecommunications. As a result of the "surrender or starve" tactic that has been utilized across Syria, many people in East Ghouta, including children, have lost their lives.

From late 2014 to February 2017, smuggling tunnels that connected East Ghouta to the opposition-held neighborhoods of Qaboun and Barzeh helped besieged residents cope with the restrictions. However, in February 2017, the Syrian government overtook Qaboun and Barzeh, sealing these tunnels and cutting off East Ghouta's access to the outside world. Today, basic food and supplies are allowed past the checkpoints, though at very high prices, making them inaccessible to civilians.

On average, a family in East Ghouta needs $200 per month to provide only for basic needs. Many heads of household earn less than $100 per month, making even the most common items a luxury. While surviving under siege, the residents of East Ghouta have been subjected to a fierce, ongoing aerial and ground campaign since 2012.

These strikes have continued in 2017, despite the de-escalation zone agreement covering the area. Fighting between opposition armed groups has worsened in recent months exacerbating the situation. Civilians have suffered the most as a result of the ongoing violence.

Denying access to health care as a tool of war has become a hallmark of the Syrian crisis, and East Ghouta is no exception. Hospitals, clinics and ambulances have been repeatedly bombed, and many health care provid-ers have been injured or killed. Since the beginning of this year, East Ghouta's hospitals and health staff have come under attack more than ten times, killing one medical staff and one patient.

SAMS staff have repeatedly referred to hospitals as the most dangerous places in Syria. This level of risk discourages patients from visiting hospitals to receive treatment. As the situation in East Ghouta becomes increasingly dire with each passing day, the medical needs of the remaining inhabitants cannot be ignored.

Challenges in Access to Health Care
Access to medical care is extremely challenging in East Ghouta. Only 107 doctors remain to treat the nearly 400,000 people, including only one neurosurgeon and one oncologist. There is one psychological medical resident to assist local civilians with the psychological effects of war, trauma, and living under siege.

In 2011, Syria had one doctor for every 600 people. In East Ghouta today, there is one doctor for every 3,600 people. East Ghouta's remaining medical professionals must adapt to a diminishing store of supplies and equipment, as these items continue to be removed from the few convoys that are permitted to enter the area.

Medicines, vaccines, medical consumables, and medical equipment are being rapidly depleted. Health workers have resorted to using old syringes and re-using disposable equipment.

Many health workers and families were forced to use medications that have been expired for two or three years. Even the most basic medications, including acetaminophen, insulin, and essential antibiotics, are in short supply. The shortages of medical personnel, equipment, and fuel have forced hospitals to reduce their operations.

The two intensive care units (ICU) in East Ghouta are only able to treat 18 people at a time, significantly reducing ICU capacity.

Women and children are particularly vulnerable to the deteriorating medical conditions. On average, there are 1,200 births per month in East Ghouta, requiring significant surgical supplies. There is a critical need for the introduction of surgical and delivery kits in order to ensure safe delivery.

Due to malnutrition, mothers are often unable to breastfeed their babies. Baby formula is extremely scarce, and women have had to watch their children suffer from hunger. Children's medications are not available in East Ghouta. Those suffering from hemophilia are unable to access factor VIII, an essential blood-clotting protein, making them at risk of death from even the most basic injury.

Patients with chronic diseases are among the most affected by the crippling siege. Thousands of patients with cardiovascular conditions, diabetes, kidney failure, asthma, and epilepsy face the risk of death as they are not able to access treatment. 550 diabetes patients are in need of insulin, yet the insulin clinics face shortages of medication.

There are no cardiac catheterization centers in East Ghouta and no access to cardiac surgery. There are 45 patients in various stages of kidney failure, 17 of whom are receiving dialysis at a drastically reduced rate.

In February and March 2017, four dialysis patients died due to the inability to access care. Similarly, cancer patients have no options for treatment and have seen their chances of survival decrease dramatically. The single oncology center in East Ghouta has only one oncologist who is unable to provide much more than a diagnosis. The essential specialized, advanced, andexpensive treatment is unavailable.

Doctors have also reported the outbreak of contagious diseases including cases of salmonella, typhoid fever, measles, tuberculosis, and cases of inflammatory liver A. In the past few months, melitensis fever has increased due to unpasteurized milk and cheese. Cases of typhoid appeared and increased in late 2013 and 2014 due to the use of groundwater wells, shallow and close to the surface.

Typhoid became an endemic disease in East Ghouta between 2015 and 2017 due to the continued use of these contaminated sources. This has resulted in cases of intestinal perforation, meningitis, and polyneuritis. Typhoid and melitensis fever kits have been prevented from entering East Ghouta. Lab kits, treatment kits, and access to clean water are critical for improving these conditions.

"Because of the medical and equipment shortage, we can't treat everybody. We are forced to choose who will live and who will die by saving the supplies we have for those who have a good chance of survival."

Awaiting Death: The Denial of Medical Evacuations
The siege's impact on the health care system in East Ghouta has caused the number of patients needing medical evacuation in order to receive treatment to rise exponentially. A list of 330 patients from East Ghouta was shared with health actors in Damascus for evacuation. These requests have repeatedly failed to receive the necessary approvals from the Syrian government.

As one SAMS doctor put it, "Many are simply awaiting their death at home." In the rare cases in which patients have been allowed to evacuate, some have died while awaiting to be evacuated outside Syria or to receive treatment in Damascus. Dr. Saif, a Syrian Arab Red Crescent (SARC) doctor in Douma said, "We have the capacity to save the lives of at least half of the people who are awaiting evacuation if 25 medications were permitted to enter."

In August 2017, four children died in East Ghouta because of the lack of medical evacuations, including Sara and Kinan. Sara, a nine year old girl with retinoblastoma, was approved to be evacuated by the Syrian government. Sadly, in August, Sara died waiting to be evacuated. Her two siblings have also lost their lives due to the same disease.

Kinan was born in East Ghouta in early 2017, exhibiting visceromegaly, enlargement of organs. Kinan and his parents visited several hospitals that had limited capacity to provide an advanced diagnosis. In June, doctors realized that Kinan was suffering from Leukemia.

Dr. Wissam, the only oncologist in East Ghouta, alerted the medical staff of his very serious and urgent case. On August 11, over two months later, Kinan passed away while his request for evacuation remained pending.

The few cases that were evacuated in 2017 provide some hope to the people awaiting evacuation, while the deaths of Sara and Kinan instill fear of facing the same fate. Even after evacuation, safety and security remain serious concerns for the evacuees.

Musa'ab Abdulnafe'e is a four-year-old child suspected to have poliomyelitis. He was evacuated with his 53-year-old father Rateb Abdulnafe'e, on May 13. On Sunday, August 13, the father was arrested while seeking to obtain an ID for his sick child.

Break the Siege
SAMS is committed to alleviating the suffering of the people in East Ghouta. SAMS operates 20 health facilities and supports two of the largest hospitals in the area. However, the siege must be broken in order to truly improve living conditions. East Ghouta is only one of at least 34 besieged communities across Syria, in which an estimated 821,210 people remain trapped. (2)

The international community must take immediate steps to end the siege in East Ghouta and all other besieged areas in Syria. In the meantime, measures to relieve the horrific conditions must be taken:

* Medical neutrality must be enforced, as mandated by international humanitarian law;

* Unconditional entry of sufficient medical supplies must be ensured, based on the needs assessments carried out by local medical staff. International monitors should be present during the entry of aid convoys in order to prevent removal of medical and other critical supplies;

* Critical medical cases should be permitted to be evacuated from the besieged area in order to access all needed treatment;

* Evacuees must have the freedom of choosing place of treatment; their safety should be monitored by UN agencies in Damascus, and the evacuees should have the right to return home or another location of their choosing after receiving treatment.

"SAMS mourns the loss of our colleagues and exemplary physicians who dedicated their lives to helping others. The international community must have a zero tolerance of these violations of international humanitarian law."
-- SAMS President, Dr. Ahmad Tarakji.

Since the beginning of the conflict, Physicians for Human Rights (PHR) has documented 478 attacks on 325 facilities in Syria, killing 826 medical personnel. Since 2015, SAMS has lost 42 medical workers.

In 2014 and 2015, as systematic and targeted attacks on healthcare increased, SAMS supported the families of our medical workers who have paid the highest price for their courage and selfless efforts.

In 2016, after the loss of yet another of our heroic medical workers, Dr. Hasan Al-A'raj, Health Director of Hama, SAMS officially launched the "Fallen Heroes Fund" to support the families who have lost a parent, a spouse and a provider, in addition to medical workers who can no longer perform their duties due to a physical disability.

With our Fallen Heroes Fund, SAMS strives to bring some comfort and hope in the face of such profound loss by supporting the families who are left behind. SAMS has committed to supporting the families of our fallen medical staff for five years.

On Saturday, March 25th, 2017, Dr. Ali Darwish, a specialist orthopedic surgeon at a SAMS-supported underground hospital in the Hama countryside, was killed in a chemical attack that hit his hospital. Dr. Darwish was one of the few medics at the facility. He was treating a patient in the hospital's operating room when the chemical attack took place.

He refused to leave his patient's side until he lost consciousness in the operating room and was evacuated to another hospital. By the time Dr. Darwish was admitted to a nearby hospital, it was too late: he died in the emergency from exposure to the chemical agent. Dr. Darwish is survived by his wife and three children.

In 2016, SAMS lost even more colleagues and heroes. In May 2016, SAMS mourned the tragic death of Dr. Hasan Al-A'raj, Health Director of Hama, who also worked in a SAMS- supported cave hospital built into the side of a mountain.

Dr. Al-A'raj was killed by a targeted airstrike, about 100 meters from the hospital. He was the only remaining cardiologist in Hama. He is survived by his wife and five children, ages 1 to 17 years old. To learn more about Dr. Al-A'raj legacy, click here.

In April 2016, SAMS also lost another invaluable doctor, Dr. Mohammed Alkos who was killed by a sniper in the besieged town of Zabadani, a neighboring town to Madaya. Dr. Alkos worked in a SAMS-supported field hospital. He was the only remaining physician in Zabadani. Dr. Alkos is survived by his wife, two sons, and daughter.

"We have difficulties with our families, as we are away, in constant danger."
-- SAMS-supported Medical Professional, Idlib, Syria

While many doctors in Syria have fled violence and targeted attacks on hospitals and health workers, Dr. Darwish, Dr. Al-Araj, and Dr. Alkos, and many others, have chosen to stay in Syria at great cost to themselves and their families.

Safety and security issues have forced many families apart, unable to visit or see each other for days at a time. Despite this unimaginable toll, many of our medical personnel remain in Syria to save lives and bring hope to the Syrian people.

"There is no safe place in Syria."
-- Medic, Idlib, Syria

SAMS healthcare workers are the greatest and true heroes. Since the beginning of the conflict, they have braved the bombardment to care for the sick, save lives, and rebuild their war-torn country. Their dedication to their work showcases the resilience and courage of medical professionals in Syria. Unfortunately, some have paid the highest price for their courage and selfless efforts.

It is our duty and responsibility to make sure those brave medics we have lost are honored and that families left behind receive the support they need.